Resolution: S-20-31: PROTECTING PATIENT SAFETY BY ENSURING PHYSICIAN QUALIFICATIONS

[Valerie Lile]

WHEREAS, mid-level practitioners, defined as, but not limited to, health-care providers such as nurse practitioners, nurse midwives, nurse anesthetists, clinical nurse specialists and physician assistants ¹  have increasingly sought expanded scope of practice with success; and

WHEREAS, nurse practitioners (NPs) now have full scope of practice in 24 states with intention to continue expansion of scope efforts ²; and

WHEREAS, NPs have introduced a new degree, DNP, or Doctor of Nursing Practice, that has increased confusion for patients in clinical settings, where said DNPs refer to themselves as doctors, and at times do not adequately inform patients that they are not physicians; and

WHEREAS, The Code of Federal Regulations defines the term physician to include doctors of medicine (MD), surgeons, podiatrists, dentists, clinical psychologists, optometrists, chiropractors, and osteopathic practitioners within the scope of their practice as defined by State law⁷; and

WHEREAS, The Social Security Administration defines physician to mean means doctor of medicine, doctor of osteopathy (including osteopathic practitioner), doctor of dental surgery or dental medicine, doctor of podiatric medicine, or doctor of optometry, or a chiropractor, legally authorized to practice by a State in which he/she performs this functions [within given parameters]⁸; and

WHEREAS, Florida, New York, Arizona, Delaware have proposed laws limiting the use of doctor to persons with a Medical Doctor (MDs) or Doctor of Osteopathic Medicine (DOs) degree; Six states have passed laws making it a felony for nurse practitioners to refer to themselves as doctor; Nine states require nurse practitioners to follow their introduction with a clarifying statement ^9,10,11; and

WHEREAS, the AMA has resolved to: (1) work jointly with state attorneys general to identify and prosecute those individuals who misrepresent themselves as physicians to their patients and mislead program applicants as to their future scope of practice; (2) pursue all other appropriate legislative, regulatory and legal actions through the Scope of Practice Partnership, as well as actions within hospital staff organizations, to counter misrepresentation by nurse doctoral programs and their students and graduates, particularly in clinical settings; and (3) work with all appropriate entities to ensure that all persons engaged in patient contact be clearly identified either verbally, or by name badge or similar identifier, with regard to their professional licensure in order that patients are aware of the professional educational background of that person ¹²; and

WHEREAS, AOA H324-A/14 states the AOA opposes non-physician clinicians use of the title physician or doctor because such communication is likely to deceive the public by implying that the non-physician clinician is engaged in the unlimited practice of medicine; opposes legislation that would expand the use of the term “physician” to persons other than US-trained DOs, and MDs; supports a policy that physicians and non-physician clinicians identify themselves to their patients noting their degree in both a verbal description as well as a visual identification by use of a nametag; will not support legislation, which would allow non-physician clinicians to be called “physician;” supports a policy reserving the title “physician” for US-trained DOs, and MDs who have established the integrity of their education, training, examination and regulations for the unlimited practice of medicine; and opposes the misuse of the title “doctor” by non-physician clinicians, in all communications and clinical settings because such use deceives the public by implying the non-physician clinician’s education, training or credentialing is equivalent to a DO or MD¹³; and

WHEREAS, attempts at promoting mid-level practitioners to independent practice is done without proper reverence to their important purpose in healthcare, as mid-level support for physicians; and

WHEREAS, such attempts are often aided by a gross oversimplification of the crucial role belonging to the primary care specialties to which NPs are often assumed to enter; and

 WHEREAS, one major justification for the expanded numbers of these practitioners and their scopes of practice is the physician shortage, which is projected that by 2025, demand for physicians will exceed supply by a range of 46,000 to 90,000³; and

WHEREAS, we acknowledge that the physician shortage is a real and serious problem on the horizon, but we also cannot afford to sacrifice patient safety or care in the name of momentary expediency; and

WHEREAS, American physicians, Medical Doctors (MDs) or Doctor of Osteopathic Medicine (DOs), undergo one to two and a half additional years of schooling, three additional years of residency training, and fifteen to eighteen thousand more training hours than “Doctors of Nursing Practice”⁴; and

WHEREAS, physicians are trained to direct and lead care, while midlevel providers such as nurse practitioners are not, the DNP degree is administrative in nature and not an advanced clinical degree; and

WHEREAS, there is inadequate evidence to support a transition to midlevel independence; and

WHEREAS, we must applaud and support nurse practitioners stance that their educational model is “patient centered” and “holistic”, we must interject that they are not unique in this view point and reject the accusation that the “medical model” is “disease focused”; and

WHEREAS, continually expanding midlevel provider scope of practice creates an opportunity for a two tiered healthcare system to develop, where rural and underserved populations have limited access to physician providers while those in larger cities have greater access to physician providers, further exacerbating existing disparities in healthcare; and

WHEREAS, the AOA has previously called for a review and validation of nonphysician credentials and standards of care and supported a position that patients should be made clearly aware at all times if they are being treated by a non-physician provider or clinician (H634-A/15)⁶, therefore, be it

RESOLVED, that SOMA adopt the following position mirroring the AOA position as currently outlined in H324-A/14, namely that SOMA members (1) are encouraged to use the terms “physician” or doctor to describe themselves once they have graduated medical school, leaving other terms such as “practitioner,” “clinician,” or “provider” to be used by non-physician clinicians or to categorize health care professionals as a whole; (2) support the appropriate use of credentials and professional degrees in advertisements; (3) support providing a mechanism for physicians to report advertisements related to medical care that are false or deceptive; (4) oppose non-physician clinicians use of the title physician or doctor because such communication is likely to deceive the public by implying that the non-physician clinician is engaged in the unlimited practice of medicine; (5) oppose legislation that would expand the use of the term “physician” to persons other than US-trained DOs, and MDs; (6) support a policy that physicians and non-physician clinicians identify themselves to their patients noting their degree in both a verbal description as well as a visual identification by use of a nametag; (7) will not support legislation, which would allow non-physician clinicians to be called “physician;”(8) support a policy reserving the title “physician” for US-trained DOs, and MDs who have established the integrity of their education, training, examination and regulations for the unlimited practice of medicine; and (9) oppose the misuse of the title “doctor” by non-physician clinicians, in all communications and clinical settings because such use deceives the public by implying the nonphysician clinician’s education, training or credentialing is equivalent to a DO or MD; and, be it further

RESOLVED, that SOMA support independent research on the qualifications and outcomes of nurse practitioners and other midlevel providers that practice independently; and, be it further

RESOLVED, that SOMA advocate to the AOA to support independent research on the qualifications and outcomes of nurse practitioners and other midlevel providers that practice independently.

___________________________________________________________________________

Explanatory Statement

Commonly it is asserted that midlevel providers provide access to rural communities. Firstly, the data shows that midlevel providers such NPs and PAs do not practice in rural areas in a statistically meaningfully different pattern as compared to physicians. Second, it is unjust to reinforce a two tiered health care system by creating policy that promotes rural community care that is highly dependent on midlevel providers. Instead the policy focus should be to attract and retain physicians in rural areas. To solve a physician shortage, we must focus on physician policy.

References

1. Catherine S. Bishop, Dnp, Np, Aocnp®. (2012). Advanced Practitioners Are Not Mid-Level Providers. Journal of the Advanced Practitioner in Oncology, 3(5). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4093350/
2. Carlson, K. (2017, March 2). NP Practice Authority Grows – March 2017 Update. Retrieved February 22, 2020, from https://nurse.org/articles/nurse-practitioner-scope-of-practice-expands-mar17/
3. AAMC. (2015, March 1). Physician Supply and Demand Through 2025: Key Findings. Retrieved February 22, 2020, from https://www.aamc.org/download/426260/data/physiciansupplyanddemandthrough2025keyfindings.pdf
4. Primary Care Coalition. (n.d.). Compare the Education Gaps Between Primary Care Physicians and Nurse Practitioners. Retrieved from https://www.tafp.org/Media/Default/Downloads/advocacy/scope-education.pdf
5. H634-A/15, AOA HOD Cong. (2015) (enacted)
6. 20 CFR 702.404 – Physician defined. (n.d.). Retrieved February 25, 2020, from https://www.law.cornell.edu/cfr/text/20/702.404
7. SSA – POMS: HI 00401.295 – Physician Defined. (2015, April 06). Retrieved February 25, 2020, from https://secure.ssa.gov/poms.nsf/lnx/0600401295
8. DECAPUA, D. (2016, April 28). Are Nurse Practitioner Doctors Real Doctors? Retrieved February 24, 2020, from https://www.bartonassociates.com/blog/are-nurse-practitioner-doctors-real-doctors/
9. Harris, G. (2011, October 01). When the Nurse Wants to Be Called ‘Doctor’. Retrieved February 24, 2020, from http://www.nytimes.com/2011/10/02/health/policy/02docs.html
10. State medical boards trying to limit who can be called “Doctor”. (n.d.). Retrieved February 24, 2020, from https://www.clinicaladvisor.com/the-waiting-room/state-medical-boards-trying-to-limit-who-can-be-called-doctor/article/284167/
11. D-35.992, AMA BOT Cong. (2016) (enacted)
12. H324-A/14, AOA HOD Cong. (2014) (enacted)

____________________________________________________________________________

Submitted by:

Wessley Square, OMSIV- Philadelphia College of Osteopathic Medicine
Harris Ahmed, OMSIV- Burrell College of Osteopathic Medicine at New Mexico State University
Joya Singh, OMSIV, Burrell College of Osteopathic Medicine at New Mexico State University
Yunus Bekir Tekin, OMSI, Burrell College of Osteopathic Medicine at New Mexico State University
Furzan Azam, OMSII, AT Still University College of Osteopathic Medicine

Action Taken:
Date:
Effective Time Period: Ongoing

[Author]

Posts